MES 303: Shoulder & Arm Conditions & Rehabilitation PDF

Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 MC (most common): Middle ⅓ (between the jxn of...

Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 MC (most common): Middle ⅓ (between the jxn of medial & lateral end Sternoclavicular Dislocations Anterior: Treatment: More common (⅔ of all cases) Splint (Immobilized) or Figure of 8 Bandage: 6 Direct trauma to the SC joint weeks healing Medial end of the clavicle becomes more ○ Immobilization: 3 to 6 weeks prominent Non-displaced or has a good alignment Px Surgery: MOI (Mechanism of Injury):High energy (MVA, contact ○ 15 to 20mm muscles shortening d/t sports) displacement. ○ (+) Skin tenting to elevated clavicle that Posterior: is almost in the middle because middle Less common clavicle fx is common More painful & severe Vascular problems Acromioclavicular Joint Mediastinal structures at risk Breathing & swallowing difficulty Note: SC jt. D/L allots for less than 1% of all jt. D/L in the body Ligaments: 1. Acromioclavicular ligament 2. Coracoclavicular ligament 3. Coracoacromial ligament Imaging Plain serendipity radiographic views and AP views CT studies are generally required to assess for direction of displacement. ○ Study of choice Mx Treatment is generally observation of atraumatic or chronic anterior dislocations ○ Sling, observation Type of AC Joint Sprains Closed versus open reduction is indicated for acute dislocations Clavicular Fractures ➔ The fracture is based on fracture location Location: Medial and Distal 3rd of the clavicle Clinical Features: Pain in the shoulder region Complete: obvious deformity Imaging: X-RAY MOI: FOOSH or FOS Age: less than 25 years old (Adventurous) Clinical Features: Elevation of AC Joint by: Myem De Jesus Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 Space in between shoulder - Can cause musculocutaneous nerve injury Px will complaint pain during palpation, and 2. Bankart Lesion ROM - Most common lesion associated with anterior AC Joint is displaced: Type 3-6 patients dislocation - Location: Anteroinferiro direction of the Labrum Provocative Test for AC Joint Impingement 3. Hill-sach Lesion Acromioclavicular Compression Test - Compression fracture of the posterolateral ○ Horizontal Test across the midline aspect of the humeral head - Associated with anterior dislocation Imaging: X-RAY Clinical Features:Anterior Dislocations ○ Should a be weighted There’s a feeling that the shoulder may be more Treatment: dislocated when shoulder abduction rotation is It depends on the different degree of separation done of injury Pain and tenderness Asymptomatic (Type ½): Full range of motion Deformity is present Posterior Shoulder Dislocation MOI FOOSH, FADIR Associated Injuries 1. Lesser Tuberosity Fracture - Can cause problems in internal rotation 2. Bennett’s Lesion - Ossification of the posteroinferior glenoid rim 3. Reverse Bankart Lesion Glenohumeral Joint (GHJ) Injuries - Posteroinferior Labral Lesion 4. Reverse Hill-Sachs Lesion - Compression fracture of the anteromedial aspect of the humeral head Provocative Tests Anterior Subluxation ○ Apprehension Test ○ Happens with stroke patients ○ Relocation Test Instability ○ Anterior Drawer Test ○ A translation of the humeral head on the ○ Anterior Load and Shift Tests glenoid fossa; may result to dislocation Posterior or subluxation ○ Jerk Test ○ Posterior Drawer Test Dislocation ○ Posterior Load and shift test ○ Complete separation and can be anterior ○ Multidirectional: Sulcus sign or posterior direction Imaging Subluxation X-RAY ○ Translation complete or incomplete ○ Scapular wide view separation of humeral head from the ○ Axillary wide view: Glenohumeral glenoid fossa with immediate reduction Dislocation ○ West Point Lateral Axillary: Bankart Anterior Dislocations: most common Lesion MOI ○ Stryker Notch View: Hill-Sachs Abduction and ER Direction Anteroinferior Note: Avoid D2 Flexion PNF Pattern Associated Injury 1. Axillary Nerve Traction (Circumflex N) by: Myem De Jesus Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 External rotation: locking Provocative Test Load and shift test O'brien Test Imaging X-RAY/ MRI Ultrasound: viewable but not accurate Treatment (Conservative) Treatment Pain medications ROM Sling:first few weeks Isometric exercise Therapeutic exercise ADLs modification Quadman Exercise ROM Exercise Impingement Syndrome and Rotator Cuff Tear Strengthening exercise ➔ Common cause of shoulder pain ➔ Cause of fusion in biceps tendon Glenoid Labrum Tears ➔ Most common impinge tendon: supraspinatus tendon ➔ Elderly Patients: rotator cuff tear (partial or complete) Primary Impingement Glenoid Labrum Impingement is the primary cause of pain ➔ Cartilage that deepens the fossa (Anatomical) ➔ There are several tendons inserted: mainly ○ Hooked Acromion (III) to subacromial rotator cuff and biceps bursitis ➔ Tear = rotator cuff or biceps problem Thick Coracoacromial Ligament ○ MC Cause of Anterior SH Pain SLAP Lesion ➔ Superior Labrum Anterior-Posterior Secondary Impingement ➔ Lesion at the site where the bicep tendon Caused by underlying attaches to the labrum Glenohumeral Instability Scapulothoracic dyskinesia MOI Weak Scapular Stabilizer FOOSH ○ Sudden traction to biceps Acromion Morphology ○ Throwing Activities ○ Deceleration when throwing (Lock-cocking phase) Types of SLAP Lesion: Type 1: Flat Type 2: Curved Type 3: Hooked Clinical features Pain during range of motion Pain during adls (overhead reaching) Pain during sports (overswing) Swimmers: freestyle, backstroke, butterfly Clinical Features Similar symptoms with shoulder instability Pain from clicking by: Myem De Jesus Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 May be impinged between the head of the humerus, acromion, and coracoclavicular ligaments with elevation and internal rotation of the arm MC site of rupture Proximal end of the long head of biceps tendon Clinical Features Point tenderness in the bicipital groove’ Positive impingement signs if associated with impingement syndrome Sharp pain, audible snap, ecchymosis, and visible bulge in the lower arm with the tendon rupture Provocative Test Provocative Test Ludington’s Test Hawkins-Kennedy Test Popeyes sign Neer’s Test Imaging Non-specific Imaging X-RAYS Treatment: MRI (gold standard of diagnostic test) Tendonitis Arthrogram ○ Conservative treatment is appropriate- Ultrasound ROM and strengthening ○ Modalities: focused in inflammation and Treatment pain ○ Injection into the tendon sheath is controversial because it can cause rupture Rupture ➔ Rotator Cuff: 4 weeks ○ Tendon reattachment is not indicated in ➔ Steroids: up to 3 per year because may weaken most patients collagen ○ Biceps Tenodesis: younger individuals who require heavy lifting may need Degenerative Joint Disease of the Shoulder reattachment (Osteoarthritis of the Shoulder) ○ Some patients may request reattachment of biceps tendon for MOI cosmetic reasons Narrowing of space of the glenohumeral joint Arthritis can be a combination of GH Joint Arthritis or AC joint; destruction of cartilage Calcific Tendonitis of the Supraspinatus Tendon Present in post-traumatic lesions, patients with ➔ Calcium deposits (Hydroxyapatite) rotator cuff tear ◆ most commonly involving the supraspinatus tendon Treatment ➔ Idiopathic: no origin or cause Joint Protection Techniques ➔ SS and Sx Medications ◆ Sharp pain in the shoulder ROM, ○ Paracetamol particularly with shoulder abduction and Supplements overhead activities Severe: Surgery Imaging X-RAY Biceps Tendon and Rupture ○ AP X-RAY Treatment: ➔ Inflammation of the long head of biceps tendon NSAIDS ➔ Seen in age > 40 years with Hx of impingement Steroid Injections ➔ (+) rotator cuff tear in elderly PT (Thera Ex) MOI Modalities-Shockwave Therapy UTZ guided needle lavage-or Barbotage by: Myem De Jesus Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 Surgical decompression of CaDeposits Adhesive Capsulitis ➔ Most common painful shoulder with restricted glenohumeral joint flexion and abduction ➔ Can cause contracture of the shoulder joint ➔ Idiopathic ➔ 40+ years, patients with CVA stroke Treatment Diagnostic Study: EMG-NCV to assess LTN and spinal accessory nerve Nonoperative Observation, Physical Therapy/Activity Modification PT: Serratus anterior strengthening, stretching Avoid painful or heavy lifting activities Bracing with a modified thoracolumbar brace can Clinical Features be considered Outcomes AKA: Diabetic Periarthritis ○ Majority of patients will spontaneously Idiopathic resolve with full return of shoulder Gender: F>M function and resolution of winging by 2 MC in 40-60 years ol years Capsular Pattern Surgery-nerve transfer, neurolysis fusion, muscle ○ External Rotation >Abduction >Internal transfer Rotation Causes Scapular Fracture ○ Diabetes ➔ Commonly occurring in patients with other ○ Immobilization serious injuries ○ Recent Strain ➔ Very rare condition ○ Arthritis ○ Trauma Clinical Features Imaging Tenderness over the scapula and acromial X-RAY AP view, scapular Y and axillary region Arthrography Ultrasound: C Imaging LABs: TSH and HgbAIC Plain films: AP, lateral (scapular Y) and axillary views Treatment CT Scan NSAIDS and/or intra-articular steroid injections, physical therapy, heat and/or cryotherapy Treatment Surgical Closed treatment is adequate for nondisplaced ○ Capsular hydrodilatation, manipulation fragments under anesthesia, and arthroscopic lysis Arm sling followed by early ROM exercises as of adhesions tolerated, usually within 1 to 2 weeks after injury ○ It is done if the PT fails over 6 months ORIF: Large displaced fragments with no improvement Sprengel Deformity Scapular Winging ➔ “Eulenberg Syndrome” I. Medial Scapular Winging ➔ Failure of the scapula to develop and descend ➔ Result of serratus anterior secondary to a ➔ High and undescended scapula problem with long thoracic nerve ➔ Secondary to compression whenever heavy ➔ Most common congenital deformity of the weightlifting is present or heavy backpack shoulder II. Lateral Scapular Winging S/sx: ➔ Results from muscle weakness secondary to a ○ Shoulder asymmetry spinal accessory nerve lesion and it can be a ○ Short-appearing neck lesion in the posterior nerve ○ Scapula Internal Rotation ○ Smaller than usual ○ Limited Abduction by: Myem De Jesus Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 ➔ Most common non=vertebral pattern seen in the Treatment elderly Observation ➔ two-part surgical neck Surgical correction: 3-8 years old due to nerve impairment MOI Low-energy falls ○ Elderly with osteoporotic bone Snapping Scapula Syndrome High energy trauma ➔ “Scapulothoracic Crepitus” ○ young individuals ➔ Scapula rubs over the underlying ribs ○ Concomitant soft tissue and ➔ Types of sound: neurovascular injuries ◆ Gentle friction sound ◆ (Physiologic): N Classification: ➔ Louder Grating Sound ◆ Bursitis ◆ Atrophy ◆ Fibrosis ◆ Anomalous Muscular Insertion ➔ Louder Snapping Sound ◆ (+) Pain ◆ More severe ◆ Tumor Clinical Features ◆ Osteophyte formation ➔ Typically occurs in elderly women with ◆ Malunion of rib fracture osteoporosis after a fall ➔ Pain, swelling, and ecchymosis in the upper arm, Clinical Features which is exacerbated with the slightest motion Popping, grinding sound ➔ In fracture at the surgical neck, the Pain in overhead movement supraspinatus is the principle abductor (e.g, the Uncoordinated movement supraspinatus causes abduction of the proximal Weakness fragment of the humerus) Winging of scapula ➔ Loss of sensation is seen if there is neurologic Abnormal Scapular Movement involvement ➔ Diminished radial pulse Imaging X-RAY Treatment MRI Conservative: Rehabilitation, Sling and early ROM (6 weeks) Treatment (Conservative Management) Surgical: ORIF NSAIDS; Steroids Injections Modalities Complications Soft tissue massage Brachial Plexus Injuries Strengthening of the neck and periscapular Avascular Necrosis muscles Arterial Injury: Axillary Artery (uncommon but in Postural Correction older patients in surgical neck) Kinesiotaping Surgical: arthroscopic scapulothoracic Complex Regional Pain Syndrome bursectomy, scapular dissection Proximal Humeral Head Fractures ➔ Classifications: 1. Greater Tuberosity 2. Lesser Tuberosity 3. Humeral Head 4. Humeral Shaft Proximal Humerus Injury ➔ Secondary to the injury to the CNS ➔ Common among elderly ➔ The injury is initiated by an injury to the ➔ 4-6% of all fractures peripheral nerve and then impulses will go to the CNS by: Myem De Jesus Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 ➔ AKA: Causalgia; RSD ➔ Complex neuropathic pain syndrome characterized by severe pain and autonomic dysfunction that may lead to crippling contractures of the limb ➔ Distal Predominance Types: I = RSD (No nerve involvement) Thoracic Outlet Syndrome II = Causalgia (C nerve involvement) Common Sites Signs/Sensory: Between the scalenes STAMP: Sensory changes, trophic skin, changes autonomic dysfunction, motor and pain ➔ AKA: Scalenus Anticus Syndrome ◆ Between the coracoid process and pecs minor ➔ AKA: Hyperabduction Syndrome ◆ Between the clavicle & 1st rib ➔ AKA: Costoclavicular Syndrome Signs/sensory: Weakness, pulselessness, paresthesisa Test: CHARAW Costoclavicular Brace Test Halstead Test Allen’s Test Roos’ Test Imaging Adson’s Test Vascular studies Wright Test X-RAY Bone Scan Treatment EMG-NCV Conservative: Blood Test ○ Analgesics, NSAIDS, Muscle relaxants, massage, hydrotherapy, PT Behavioral Modification or avoidance of provocative activities Improvement: 50 -90% Surgical by: Myem De Jesus Week 2: Conditions & Rehabilitation of Shoulder, Arm, Distal Humerus MES 303: Orthopedic, Rheumatologic, Industrial, and Sports Rehabilitation BS Occupational Therapy 3-1 Past Boards Answer: C Answer: C Answer: C Answer: D Answer: C Answer: D Answer: D by: Myem De Jesus